Deficiencies in Care Planning and Implementation
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for three residents, leading to deficiencies in their care. Resident #25 was observed with only one floor mat in place, despite a physician's order for two mats to prevent falls. The care plan for this resident did not include interventions for floor mats, and staff were unaware of the correct protocol, resulting in the resident being found on the floor multiple times. Resident #52 was also affected by inadequate care planning, as they were observed with only one floor mat in place, contrary to the prescribed two mats. The staff failed to communicate effectively about the required interventions, and the resident was found on the floor on several occasions. The care plan for this resident did not adequately address the need for floor mats, contributing to the risk of falls. Resident #95 experienced a deficiency in care related to the administration of oxygen. The resident was observed receiving oxygen at a rate lower than the physician's order, which led to a dangerously low oxygen saturation level. The staff did not verify the oxygen delivery rate during rounds, resulting in a delay in adjusting the oxygen to the prescribed level. This oversight in care planning and execution posed a significant risk to the resident's health.
Plan Of Correction
Immediate Action: Resident sample #25 - care plan was reviewed and revised to include implementation of floor mats per physician orders by the MDS Nurse. Resident sample #52 - floor mat was placed as per physician orders and care plan. The Nurse and CNA were educated by the Nurse Manager on the expectation of following physician orders and/or implementing the identified appropriate care plan interventions for floor mats. Resident sample #95 - the flow rate was increased from 1.25 liters per minute to 2 liters per minute as per physician orders and care plan. Saturation was checked and reported to the Hospice team. The Nurse was educated by the Nurse Manager on the expectation of following physician orders and/or implementing the identified appropriate care plan interventions for use. Identification of Residents with potential to be affected: All residents in the facility have the potential to be affected. Interdisciplinary review and verification of care plan interventions and orders for floor mats and use. System Changes: The facility Prevention Policy and Medication Administration Policy were reviewed for accuracy. Nurses and CNAs were educated and trained on the Falling Star Program and use of floor mats and resident use as indicated in the physician orders and care plan by the Director of Nursing and Risk Manager. Licensed nursing staff are to verify and document in the Treatment Administration Record the use of floor mats and orders for use every shift. Licensed nursing staff were educated by the Director of Nursing and the Assistant Director of Nursing on medication.